Oral Oncolytics in CLL: Take-Home Messages

Concluding their conversation on access to oral oncolytics in chronic lymphocytic leukemia (CLL), the experts share their closing thoughts on how the treatment paradigm will evolve in upcoming years.

Transcript

Troy Trygstad, PharmD, PhD, MBA: This time, Christina, I’m not the patient. I’m the patient’s son, and my mother just called me and said, “I have CLL, and I’m a little bit worried that we’re not going to be able to afford these medications.” Where do I start as a family member? Where do I go? How do I learn about this? This is the first time I had somebody in my family who’s had this traumatic of a life event. Where do I start?

Christina Patterson, PA-C: It’s a very common scenario in our practice. So first of all, we would often want to make sure the patient’s family is educated about the disease process and the treatment plan. Then we would make sure they have the appropriate education regarding disease state and treatment. But then we’d also have them meet with our staff regarding the financials. So when a provider decides to start an oral oncolytic, they meet with our staff, and some of the screening questions that they go through include: Are they eligible for VA [Veterans Affairs] benefits, or what is their insurance? Do they even have insurance? Is it a Medicare Part D plan? Often in this population it is, or if they don’t have insurance, are they eligible for any other programs? And then we have them meet with the appropriate members in our office, our patient advocate, or sometimes we have to refer them to our cancer center locally to help with the other programs. But then we also screen for other programs like the Medicare Low-Income Subsidy, or we start collecting the financial information. We tell them we do whatever we can to make sure they get the appropriate treatment.

Troy Trygstad, PharmD, PhD, MBA: I live in North Carolina, my father lives nearby, and my mother lives near Bemidji, Minnesota. Kirollos, they’ve gone anywhere from South Florida to Mayo Clinic to Sanford Health up in Bemidji, and when this happens, they’re disoriented with the whole financing and everything else. How does that information get to me in Chapel Hill, North Carolina?

Kirollos Hanna, PharmD, BCPS: What I always do, what I always recommend to patients or their caregivers, is ask. So the first thing is going to be for that patient or their caregiver to ask the provider how much this is going to cost. Me, I’m in practice, but I don’t have $15,000 or $20,000 to spend each month on my oral oncolytic. There is really no shame or harm in asking your provider because that provider or that nurse coordinator or whoever works in that department will be able to direct the patient to the correct people such as the financial advocates. Most large academic centers will have financial counselors or financial advocates that will work with a patient’s insurance companies and work on these foundations and are well versed in this information.

Troy Trygstad, PharmD, PhD, MBA: So your public service announcement to folks like me is much like Kobe Bryant’s, which is you miss 100% of the shots you don’t take.

Kirollos Hanna, PharmD, BCPS: Exactly.

Troy Trygstad, PharmD, PhD, MBA: So go ahead and take as many shots as you like.

Kirollos Hanna, PharmD, BCPS: Absolutely, absolutely.

Troy Trygstad, PharmD, PhD, MBA: OK, fair enough. Go ahead, Mike.

Michael Reff, RPh, MBA: Well, I’d like to build on that because that’s a great example that I was thinking of. We had a presenter at the NCODA [National Community Oncology Dispensing Association] meeting who talked about that specific example where he’s an educated gentleman, got a diagnosis of multiple myeloma, went online, and realized that his foundation support from one provider that he was seeing was going to run out of funds. In the meantime, he got new insurance. And because he got new insurance, he could go to another clinic closer to his house. So he didn’t need to go here; now he could go there. And so not only was his foundation and his ability to get this oral therapy stopping, he was also over here with a new clinic that didn’t know him as well.

But it was a community oncology practice that has a medically integrated dispensing service, and this gentleman at home, nearly in tears, kept looking for foundation support online and went and scoured the internet, made all kinds of calls, and came up with nothing. His example was how 3 minutes at the practice, the pharmacist said, “I’ll be right back.” And he said, no kidding, within 3 minutes he came back with a whole year’s foundation support. And he said had he known that there were people there who cared for him as much as he would have liked and that took the time, energy, and effort to uncover that, he would have started there at the beginning, obviously. But he was just thrilled at the service that he got at his clinic and the fact that he asked the question.

Kirollos Hanna, PharmD, BCPS: And it’s really important because Google, Dr. Google, will give you numerous answers, and patients already are overburdened with their diagnosis, whether it’s new or not, [and] change of therapies. And you really want to minimize that, so I really advise those patients to ask. One of the very first things I do when I get a new oral oncology prescription from a provider or get notified is check that they picked the right drug for the right indication and that is the plan. The second thing I do before even assessing drug—drug interaction and everything else is tell my financial coordinator, “Hey, Bob Smith started on drug X. Please begin looking into benefits investigation.” And then any other conversation I need to have with the provider, whether it’s an interaction or monitoring and such, can come after because oftentimes in starting that patient on therapy, the rate-limiting step is the financial piece.

Troy Trygstad, PharmD, PhD, MBA: Well done, panel. We always end with speed rounds. My speed round question is: In your opinion—we’ll start with Kirollos—what is the most exciting development upcoming in oral oncolytics?

Kirollos Hanna, PharmD, BCPS: So I think in oral oncology, one of the most exciting things is potentially seeing this Proteus technology that we discussed earlier in our panel discussion, whether this will really be a tool that we’re able to utilize in practice in assessing adherence. There are several barriers that are going to come with this, one of which is you’re encapsulating a drug product that technically requires a pharmacy to compound a medication per se. You’re taking a pill and putting it inside a capsule. So what are the regulations behind that, especially because you’re dealing with oral chemotherapy or chemotherapy, so there’s that hazard risk. So what are pharmacies going to be doing? In addition to that, how are we going to streamline it for patients? Do patients want to walk around all day carrying an iPad? Do they want a patch? So it’s exciting, but is this the optimal route to take? But I think a tool to assess adherence will be huge. And then secondly, what we’ve been talking about is figuring out the money issue. We’ve mastered it in infusion. I think we have the potential and resources to do it in oral oncology. We just need to all communicate.

Troy Trygstad, PharmD, PhD, MBA: So, Christina, Kirollos cheated, he gave me 2 speed rounds. What is the most exciting evolution in oral oncolytics upcoming?

Christina Patterson, PA-C: I think just the future development, the amount of oral oncolytics.

Troy Trygstad, PharmD, PhD, MBA: The number of options.

Christina Patterson, PA-C: Yes.

Troy Trygstad, PharmD, PhD, MBA: Number of treatment options.

Christina Patterson, PA-C: The number of options.

Troy Trygstad, PharmD, PhD, MBA: So we have the adherence EKG [electrocardiogram] and a more streamlined patient assistance, the wider availability of treatment options. Sorry to make you last, Mike, but what is the most exciting development upcoming?

Michael Reff, RPh, MBA: I love their examples of innovation. We absolutely want to see that continue. But I believe it’s really that continuity in care and organizations like NCODA working with payers.

Troy Trygstad, PharmD, PhD, MBA: So the emergence of enhanced services as a practice model.

Michael Reff, RPh, MBA: As a practice model, trying to unshackle the patient from receiving the therapies that they need as soon as they can and being able to afford them because we got the teams here at the practice to provide them with passionate financial support resources. So it’s really taking the model that we’ve piloted at 8 locations and working across other practices to go beyond the first fill with regional payers and maybe potentially some national payers.

Troy Trygstad, PharmD, PhD, MBA: Excellent. Well, thanks for joining us today in this Specialty Pharmacy Times® Peer Exchange. We’ll see you next time.